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grains each, beginning six hours before the paroxysm is expected and given hourly until all five doses are taken. The last dose of the quinine will, of course, be taken an hour before the time that would be occupied by the chill. I have no reason for believing that the antiperiodic virtues of quinine are exhausted by giving it in one large dose, as Hertz and others advise. I order the antiperiodic taken as stated above for three consecutive days. It is given with advantage in this manner over the practice of giving what we consider the antiperiodic quantity any time in the interval. One reason is that during the time quinine is being taken we can keep the patient indoors till the time of the chill has passed, while, if it is taken in the sweating stage, the patient might go out, unduly expose himself, and bring on the paroxysm. Then, given in this manner, we are more assured that the malarial poison is neutralized; besides, the production of cinchonism for three consecutive times will make the chances for the return of the chill almost inconsiderable. The experience of several great observers would seem to confirm this position. Professor Flint declared the chances that cinchonism produced in the interval would ward off a recurring attack was about equal with failure. It would seem that Professor Loomis favors this plan of producing several cinchonisms. He says, "Having prevented the recurrence of a second paroxysm, it is important that a moderate degree of cinchonism should be maintained for a number of days by the daily administration of quinine, in moderate doses, about two hours before the time of day at which the first paroxysm occurred; ten to fifteen grains should be daily administered."* I have found the antiperiodic given in the sweating stage often produced vomiting. But granting that it will not produce even nausea, the fact that the patient might go out and bring on another paroxysm is sufficient, together with the fact that no advantage would be gained, to condemn the practice. Since I have begun to give the antiperiodic later in the interval my success has been greater. My experience has led me to the conclusion that quinine given in solu

*Loomis' Practice of Medicine, p. 116.

tion is not more certainly antiperiodic. Fluids, it is well known, are more easy of absorption than powders, yet we are not on this score to ignore making our prescriptions palatable. The exhibition of quinine in capsules is a practice open to no objection if they are soluble. I have never had cause to regret using the drug in this manner. To give

it in freshly made pills is also a good way. When the stomach is irritable I order two grains of oxalate of cerium with each dose of quinine. When the agent is to be given to children, I have ceased prescribing it any other way than in the aromatic syrup of yerba santa when it can be taken by the mouth at all. It completely disguises the taste of the drug and makes it so palatable that children like it. When it is not advisible on any account to give it per os or per enema it can be given hypodermically with advantage. Given in doses of six grains hypodermically, I have found it equal to twenty taken per 08. When there is furred tongue and other symptoms of biliousness, colocynth and calomel should be added to the treatment.

Sternberg ascribes the oxytoxic powers often attributed to quinine to a misconception. I have often given women advanced in pregnancy full doses of quinine, and have never had the least reason to regard it as an abortifacient. Malarial fevers often produce abortion, and this is how the drug came to be looked upon as an exciter of uterine contractions. Cornus florida (dogwood), given as before outlined, may be used. So also may the kindred alkaloids of cinchona and the remedies mentioned above. Fifteen or twenty grains of the bromides of potassium or sodium given during the time quinine is being taken will entirely relieve the unpleasant effects of cinchonism, such as tinnitus aurium, etc. This also lessens the tendency to nausea and vomiting. Such good results follow it that I almost follow giving it in a routine way, and never fail to give it when the patient complains of the unpleasant effects of cinchonism.

In the third type removal from the malarial surroundings is imperative. The patient's general health must be looked after. Codliver oil, arsenic, and iron are the remedies

Diarrhea,

which will afford the best results. bronchitis, and whatever complications may exist, will demand special interference suitable to the particular case and not possible to outline here. Arsenic should be given until the symptoms of arsenical poison in the edema arsenicalis appear. Quinine should be directed against the chills or elevations of temperature for one month, if that long be necessary to dissipate them.

The fourth type, which is seemingly habit, calls for treatment somewhat different than the other varieties. There are several remedies which render us substantial good in these cases, and which may be relied on with confidence. The patients should be put on tonics, such as iron. I frequently prescribe tr. ferrichlor. in combination with liq. arsen. chlor. with the most satisfactory results. The best means to arrest the paroxysms are those agents which impress the nervous system. The bath of cold water is an excellent measure, used as above directed. Opium in full doses, one hour before the expected paroxysm, is one of the surest means of curing this form. It is well often to combine capsicum or piperine with the opium. Opium should be given for at least three consecutive days, or may be longer.

When the chills recur every fourteen or twenty-one days, quinine in doses of five grains, given for a period of four weeks, generally succeeds in my hands in curing them.

For the enlargement of the spleen nothing is so good as tonics and the application of the ointment of the biniodide of mercury over the site of spleen.

LOUISVILLE.

COPPER AND CONSUMPTION.-Prof. Luton, of Rheims, in a long article, concludes that a cure of tuberculosis can always be effected by means of the phosphate of copper, which, however, must be in the nascent state and soluble in an alkaline body. He thinks he has found a specific in the following formula: Neutral acetate of copper, gram 0.15; crystallized phosphate of sodium, gram 0.75; glycerine and powdered licorice, each, a sufficient quantity. This for one pill.-Medical Record.

COCAINE TOXEMIA.*

BY J. B. MATTISON, M. D.

At a meeting of the New York Neurological Society, November 5, 1886, Dr. William A. Hammond, in the course of "Some Remarks on Cocaine," expressed his disbelief in the toxic power of that drug, declaring "he did not believe that any dose that could be taken was dangerous." In a paper by the writer on "Cocaine Dosage and Cocaine Addiction," read before the Kings County Medical Society, February 15, 1887 (reprint may be had if desired), evidence was presented to prove this opinion a mistaken one. This proof, furnished by forty different authorities, English, French, German, Austrian, Russian, and American, cited more than fifty cases to support the assertion that there is danger, near and remote, in the use of this drug on some patients, that does not warrant such reckless disregard of care as the opinion referred to implies.

The cases noted more or less in detail showed that cocaine caused toxic symptoms so marked in four as to be fatal. The amount of the drug used varied from a small fraction of a grain to twenty-four grains, and was applied to the eye, ear, nose, throat, larynx, teeth, gums, stomach, bowel, bladder, uterus, urethra, and under the skin. The symptoms noted were nausea, vomiting, headache, deafness, blindness, loss of taste and smell, profuse sweats, cold perspiration, lividity, gastric cramp, frequent, feeble, irregular, intermittent, uncountable pulse; shallow, gasping, irregular, difficult, convulsive, suspended breathing, artificial respiration required in some cases; gait, speech, and swallowing greatly impaired; rigid muscles, palpitation, sense of suffocation and great constriction about the chest; loss of motion and sensation in arms and legs; general numbness; intense restlessness, extreme prostration, giddiness, faintness, feeling of impending death, unconsciousness, convulsions, paralysis, hallucinations, mania, delusions, delirium, and death. Summarizing, it was asserted:

Cocaine may be toxic, sometimes deadly, in large doses.

*Read before the American Association for the Cure of Inebriates, November 8, 1887.

It may give rise to dangerous or even fatal symptoms in doses usually deemed safe.

The danger, near and remote, is greatest when given under the skin.

In further proof of these conclusions, added evidence of over forty cases is herewith appended.

a solution of the drug containing altogether about five grains of muriate of cocaine. In about fifteen minutes, without any premonitory symptoms except a little nausea and faintness, she was seized with violent general convulsive movements, which were so strong and so much more pronounced on the right side, on which she was lying, as to turn her over on her belly. She had opisthotonos, entire loss of consciousness for about five minutes, after which it gradually returned, and seemed entirely restored at the end of fifteen minutes.

Two more cases of fatal effect from cocaine have been reported, one in dental practice in Poland, the other in France, but the writer has not yet been able to secure the desired details. Dr. Samuel T. Earle (Maryland Medical Asphyxia; muscles of the lower jaw violently Journal) noted these cases:

"Mr. Z. presented himself for the treatment of hemorrhoids. Found on examination one external and several small internal hemorrhoids, which I decided to remove by the clamp and cautery. March 5th, I proceeded to do the operation. I injected in the sub

cutaneous tissue around the anus about one dram of a four-per-cent solution of cocaine, which amounted to about two grains of the drug. In about five minutes after the injection, and before I had taken any other step in the operation, he complained of strange feelings in his legs, accompanied by a twitching of the muscles. In a few minutes more these twitchings amounted to decided general tetanic convulsive movements, which involved all the muscles of the trunk and extremities. By the time these convulsive movements had become general he complained of fullness in the head and soon became unconscious, remaining so for about five minutes. As the convulsive seizures gradually subsided he regained his consciousness, but that too only gradually. For instance, would answer me, look bright, and said he felt all right, but in a few seconds more would complain of fullness in his head and become drowsy. This occurred several times before he recovered entirely. Altogether the attack lasted about half an hour. His pulse was weak, although it could not be felt very well on account of the convulsive movements. Pupils slighted dilated. The following day found the patient doing very well, only complaining of some soreness in his muscles."

CASE 2. Female: operation for hemorrhoids; cocaine to produce local anesthesia. "I injected

convulsed; pupils unevenly dilated after consciousness began to return; mouth drawn to the right side; speech decidedly thickened for some minutes after return to consciousness; respiration very labored, and at the height of the attack was arrested for some seconds; pulse very feeble; cutaneous surface was decidedly blanched, where not purple, until after consciousness began to return, when it alternately became flushed and pallid; she now broke out in a profuse sweat. There was great prostration following the attack and a disposition to sleep. She recovered entirely after several hours, and only complained of feeling tired. This patient had never had any nervous attack of any kind previously, and both patients were remarkably robust and healthy."

Dr. J. Howell Way (Medical News) asserts his personal experience with cocaine was "an experiment which proved a very dangerous one, and came very near terminating fatally." At 6 P. M. he injected one fourth grain of Squibb's cocaine under the skin of his fore-arm. No result ensuing, the injection was repeated in fifteen minutes. At 6:30, general symptoms not having appeared, one half grain was taken, making one grain within half an hour. In ten minutes systemic effects began; he became restless, respirations 30, shallow and sighing; pulse 120; had aphasia and increasing precordial oppression.

It was now 6:50 P. M. Twenty minutes had elapsed since taking the half-grain injec tion. My pupils were dilating slowly; mental faculties perfectly clear and collected; no pain in head or other part of body; respirations reduced to normal frequency, but very shallow

and sighing; pulse 140, quick, feeble, and barely perceptible at wrist. I walked about the room for three or four minutes, when I grew weak and exhausted, and was compelled to lie down on the lounge.

At 7:20 P. M. my condition was almost that of collapse. Mental faculties perfectly clear and natural; pupils widely dilated; mouth dry, and a sensation as of the presence of a foreign body in the pharynx; respirations shallow, sighing, and reduced to 11 per minute; pulse elevated to 180, very feeble, fluttering, and extinct at wrist; extremities cold; body was warm to the touch, but my own sensations were those of intense cold. I was placed in front of a large fire and my body enveloped in heavy woolen blankets while my feet and hands were briskly rubbed.

A sense of impending dissolution came over me, not a feeling of fear, but a conviction that my physical condition was such that death was almost inevitable. My mind remained perfectly clear, and I gave my attendants all directions as to my care. I took frequent doses of ammonia and digitalis; the former seemed to be of very great advantage.

At 7:30 P. M. my condition was worse, and myself and attendants were momentarily expecting my death. My extremities seemed to lose all power of either motion or sensation. I struggled against this with all my will-power, and would call for frequent doses of ammonia, which would give me (so it seemed) sufficient strength to move. Painful emesis occurred twice, each time being attended with the ejection of about two ounces of white, frothy matter, which soon evaporated, leaving only a faint white residuum. Respirations were now only 9 per minute, and exceedingly shallow; carotid pulse faintly beating at 200; radical pulse entirely imperceptible; no impulse of heartbeat felt on palpation. Mind still clear. Suffered no pain.

I remained in this state for about half an hour, during which, in addition to frequent small doses of ammonia and digitalis, I inhaled three drops of nitrite of amyl. A marked improvement in the cardiac action was now noted. Respirations had increased to 14 per minute, pupils contracted to normal, and skin

Im

became moist and warm. At 10 P. M. the radical pulse returned, was full and reduced to 140. Respirations were of normal frequency, and of almost normal vigor. provement continued. At 11 P. M. respirations normal, pulse 120. Suffered at this time from a dull aching pain in lumbar region of spine and sense of great weakness and prostration. Half an hour later very copious diuresis took place.

At 1 A. M. was entirely well save the feeling of exhaustion naturally following so great a derangement of the vital functions. Was now removed to my room and slept soundly until 8 A. M. During the day I suffered much annoyance from the very dry state of my pharynx and also from muscular weakness. Both these inconveniences disappeared during the following night.

Dr. Bullock (Boston Medical and Surgical Journal) reports the case of a man, aged twenty-four, in which he used forty minims of a four-per-cent solution by spray and injection for local anesthesia prior to tonsilotomy. Three hours later patient was suddenly seized with very severe headache, vertigo, nausea, flushed face, difficult respiration and delirum. "When I first saw him he was tossing about in bed in a half-unconscious condition, muttering to himself. I was able without much difficulty to rouse him sufficiently to answer questions, after which he quickly relapsed into his former condition.

"He complained of tingling sensations in the extremities, dryness and constriction of the throat, 'burning sensation' in the stomach, nausea and intense headache. The pupils were widely dilated, there was some cyanosis of the face, but not of an extreme degree; respiration varied from ten to fourteen, pulse was 126 and very weak. I at once administered one ounce of brandy, and a few minutes later twenty drops of tincture of digitalis. This was vomited fifteen minutes later.

"I then gave a subcutaneous injection of five grains of carbonate of ammonia, and applied hot sinapisms to the chest and epigastric region. A little latter I again gave some brandy and digitalis, and this time it was retained. In about twenty minutes the pulse

grew stronger, beating 115, and the respiration became less labored. I kept on administering brandy and digitalis at frequent intervals, and at 5 P. M. had the satisfaction of seeing the patient drop off into a quiet sleep. Pulse was 105 and quite strong, and respirations 18, while the cyanosis of the face had nearly disappeared. He slept quietly until 9 P. M., when he awoke and stated that he felt much better, but still had some headache. Pulse was 95, and respiration 20. He soon went to sleep again, and slept quietly the greater part of the night. The next morning, the 16th, he complained of a good deal of numbness and tingling in the extremities, intense dryness of the throat, and blurred vision. These symptoms gradually passed off during the day."

Dr. A. N. Blodgett (Boston Medical and Surgical Journal) cites case of Dr. R., age twenty-three, well and strong, to whom he gave subcutaneously, for local anesthesia, three minims of a twelve-per-cent solution. "Thirty seconds after the injection was made the patient began to complain of a feeling of great depression, a sensation of coldness and of faintness. It was thought at first that these sensations were due to fright, or to an undue amount of apprehension as to the action of the drug; but this proved to be erroneous. The patient rapidly became cyanosed, the breathing changed to a sighing character, the pulse was 140 and weak, the face was bathed in cold perspiration, there were short periods of profound collapse with unconsciousness. The patient was assisted to a couch, where he soon became quite helpless. Stimulants were administered, the heat of the surface was maintained, and the body warmly covered. At the expiration of a quarter of an hour the finger on the pulse showed a commencing improvement in the patient's condition. With the restoration of the organic functions came a mild form of delirium, the patient talking incessantly upon all possible subjects, and apparently not realizing that he had been in any abnormal condition. Soon the pulse was reduced to 80 per minute and the skin became warm. The delirium gradually subsided, and the patient slowly returned to his natural state.

Dr. McIntyre (St. Louis Medical and Surgical Journal) reported the case of a man, aged forty, to whom half a grain was given subcutaneously to remove results of a rum debauch. It caused partial paralysis, slow, difficult breathing, pulse of 140, and complete inability to talk or swallow. "Patient was in a serious state for some time."

Dr. Stickler (Medical Record) injected five drops of a twenty-per-cent solution prior to opening a small cyst. It caused vertigo, headache, nausea, diarrhea, and insomnia, which persisted for three days.

R. Steer Bowker reports this case: One dram of a six-per-cent solution was instilled prior to and during enucleation of an eye. Thirty minutes after the first coacaining "she became very faint, face blanched, lips cyanosed; felt very sick, pulse rapid and feeble." She rallied, but two and a half hours later the doctor was hurriedly summoned. "On my arrival she was better, though faint, with cold extremities and rapid pulse. Hot brandy and water, and she was soon all right. I used less than four grains, and yet I think it would have taken but little more in this case to have caused a fatal result." Dr. James Magill recorded the case of a guardsman of fine physique in whose foreskin he injected one grain of cocaine prior to slitting the prepuce for phimosis. In fifteen minutes patient was so extremely pallid, and complained of such precordial pain, with very slow, irregular intermittent pulse, that the operation was deferred. This grave condition lasted twenty minutes."

Galezowski reported the case of a girl, aged twelve, in whom the instillation of fifteen drops of a two per cent solution caused severe headache, marked malaise, tottering gait, and difficulty of speech as if the tongue were paralyzed, persisting thirty hours.

Adams Frost noted a lad, aged fourteen, in whose eye one drop of a one-per-cent solution was instilled. In a few minutes there were blue lips, pallor, profuse sweat, and small, slow pulse. Ammonia was given, but it was nearly an hour before he recovered.

Heuse recorded the case of a female, aged seventy, in whose eye three drops of a two percent solution were instilled, followed by great

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